State-wide implementation of patient-reported outcome measures (PROMs) in specialized outpatient palliative care teams (ELSAH): A mixed-methods evaluation and implications for their sustainable ﻿use

Background Such patient-reported outcome measures (PROMs) and patient-centered outcome measures as the Integrated Palliative Care Outcome Scale (IPOS), Phase of Illness, and IPOS Views on Care (IPOS VoC), facilitate patient-centered care and help improve quality. To ensure sustainability, implementation and usage should be adapted according to setting. When settings involve several distinct teams that differ in terms of views and working practices, it is more difficult to integrate outcome measures into daily care. The ELSAH study aimed to learn how health professionals working in specialized outpatient palliative care (SOPC) viewed the use of these outcome measures in daily care, and what they express is needed for successful sustainable, state-wide application. Methods We used a parallel mixed-methods design involving three focus groups (n = 14) and an online-survey based on normalization process theory (n = 76). Most participants were nurses and physicians from 19 SOPC-teams in Hesse, Germany. We used a triangulation protocol including convergence coding matrices to triangulate findings. Results The majority of health professionals were able to integrate the outcome measures into their working lives and said that it had become a normal part of their day-to-day work. To ensure their sustainable integration into daily care, the motivation and concerns of health professionals should be taken into consideration. Health professionals must clearly recognize how the measures help improve daily care and quality evaluation. Conclusions To implement the outcome measures in a number of teams, it will be necessary to take individual team characteristics into account, because they influence motivation and concerncs. Further, it will be necessary to offer opportunities for them to engage in peer support and share information with other teams. The sustainable use of outcome measures in SOPC will require continuous support within each team as well as across teams. When several distinct teams are working in the same setting, a cross-team coordination unit can help to coordinate their work efficiently. Trial registration German Clinical Trials Register DRKS-ID: DRKS00012421; www.germanctr.de/DRKS00012421 Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-01109-w.


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How this has been addressed Title page Title We have described the key issues and the study population. We have refrained from using qualitative or quantitative words, and referenced the term mixed-methods. Author note We report on funding, conflicts of interest, registration, affiliations, and provide contact information for the corresponding author. According to the Palliative Medicine Journal's instructions to authors, we provide some of this information on the title page and some in the declarations section. Abstract Objectives We frame the problem under investigation and state a clear research aim. Participants We describe the setting and participants in our study.

Study Method
We describe the mixed-methods design, including methods of data collection and triangulation.

Findings
We present the main results.

Conclusions
We present the major implications.

Introduction
Description of research problems/ questions We frame and synthesize relevant literature, and describe the problem of integrating outcome measures in daily care, the peculiarity of the setting of specialized palliative home-care, and the role of implementation frameworks and theory. Study objectives/ aims/research goals We provide the rationale behind using Normalization Process Theory. We describe the aim of the ELSAH study and the relation of this article to prior articles/publications. We explain the mixed-methods research aim of this article, which is the same as the aim of qualitative and quantitative methods.

Method Research design overview
We define the mixed-methods design, explain why mixed-methods are appropriate, and describe the focus groups and online-survey. Participants or other data sources We present the qualitative and quantitative data sources, and explain that our participants had the opportunity to use both methods. We present the methods in order of application. We provide the number of participants for each method.

Researcher description
We describe the researchers' experience in the methods section and their employment status in the declarations' section.

Participant recruitment Participant sampling or selection
We describe the invitation procedures for participation in the focus groups and online-survey in separate sections. We further describe cancelled participation.

Participant recruitment
We describe the setting and location, sampling method and invitation, and the informed consent procedures, as well as ethics approval and accordance with the Declaration of Helsinki.

Data collection Data collection/ identification procedures
We describe data collection strategies and discuss them in the strengths and limitations section. The focus group topic guide and the online-survey questions are available in the supplemental material. We mention the mean duration and duration range of the focus groups, and the duration of the online-survey. Recording and transforming the data We describe video-recording and transcription for the focus groups and the 'lime-survey' platform used in the online-survey. Data analysis Validity, reliability, and methodological integrity We describe the qualitative data analysis (including naming the coders, description of inductive/deductive coding, and the employed software), the quantitative data analysis (including the employed software), and the mixedmethods triangulation. We describe how the use of the triangulation protocol strengthens mixed-methods integrity.

Findings/Results subsections
We describe the qualitative and quantitative results, and how these results were integrated and mixed-methods results were derived. We present the analytic process including quotes, and highlight the key results.

Discussion subsections
We discuss similarities and differences to previous theories and research findings, reflect on explanations of the findings, discuss strengths and limitations, and transferability, and derive implications of the integrated findings from use of the two methods.